Nursing Delegation to Unlicensed Assistive Personnel in the School Setting
It is the position of the National Association of School Nurses (NASN) that the delegation of nursing tasks in the school setting can be a valuable tool for the registered professional school nurse (hereinafter referred to as school nurse), when based on the nursing definition of delegation (American Nurses Association [ANA], 2012) and in compliance with state nursing laws and/or regulations and guidance. Delegation may occur when the school nurse determines it is appropriate, but such delegation may not be appropriate for all students or all school nurse practice settings. The legal parameters for nursing delegation are defined by state laws that regulate nursing, State Board of Nursing guidelines, and Nursing Administrative Rules/Regulations (ANA, 2012; American Academy of Pediatrics [AAP], 2009).
Advances in healthcare and technology enable children with increasingly complex medical needs to be a part of the general school population. The incidence of chronic conditions such as asthma, diabetes, severe allergies, and seizure disorders in school-age children is increasing; and complex medical conditions that were previously handled in acute care settings are now being managed in the school setting, requiring school nurses to make care decisions that may include delegation where appropriate (Van Cleave, Gortmaker, & Perrin, 2010; Federal Interagency Forum on Child and Family Statistics, 2013).
Federal laws set requirements for the provision of healthcare to children in schools. For example, the Individuals with Disabilities Education Act (IDEA), Section 504 of the Rehabilitation Act of 1973, and the Americans with Disabilities Act (ADA) of 1990, include requirements to ensure that children with special healthcare needs have the right to be educated with their peers in the least restrictive environment (U.S. Department of Health and Human Services [USDHHS], 2006) and to receive support and accommodations for conditions that adversely affect their capacities for learning (Gelfman, 2005). School nurses use their expert assessment skills to appropriately delegate health-related tasks and address the specific healthcare needs of students, enabling access to a free appropriate public education (Resha, 2010).
The ANA defines nursing delegation as transferring the responsibility of performing a nursing activity to another person while retaining accountability for the outcome (ANA & the National Council of State Boards of Nursing [NCSBN], 2006). Nurses are accountable to: (1) state laws, rules, and regulations; (2) employer policies and procedures/agency regulations, and (3) standards of professional school nursing practice, including those pertaining to delegation. The decision to delegate is a serious responsibility that the school nurse determines on a case-by-case basis based on the needs and condition of the student, stability and acuity of the student’s condition, potential for harm, complexity of the task, and predictability of the outcome (ANA, 2012). Prior to delegation, the school nurse is required to perform an assessment of the student to guide the school nurse in determining the level of training and supervision required for safe delegation for this specific student. The safety and well-being of the individual student and the broader school community must be the central focus of all decisions regarding the delegation of nursing tasks (ANA & NCSBN, 2006). Delegation is used effectively in some areas, however unsafe and inappropriate delegation in school settings can occur. It is important for school districts, school nurses, healthcare professionals, parents/guardians and the public to understand what activities can be delegated and when delegation is appropriate. Due to the complexity of delegation in the school setting, school nurses should be provided educational opportunities to review current delegation practices, case studies, situational reviews, or simulations (Weydt, 2010).
Delegation in school nursing is a complex process in which the authority to perform a selected nursing task is transferred from the school nurse to a competent unlicensed individual, also known as unlicensed assistive personnel (UAP), in a specific situation. The decision to delegate and the supervision of those delegated to perform nursing tasks in the school setting rests solely with the school nurse. The school nurse makes the determination to delegate based on the nursing assessment and in compliance with applicable laws and/or regulations and guidance provided by professional nursing associations (ANA & NCSBN, 2006; Mitts vs. Hillsboro Union High School, 1987). In some states, delegation in the school setting is the responsibility of the building administrator, however the actual delegation of nursing tasks can only be designated by the school nurse. In other states, delegation of nursing tasks is not permitted. This underscores the importance of school nurses being knowledgeable of the delegation laws in the states where they practice, as nurse practice acts vary from state to state (Gordon & Barry, 2009).
Nursing tasks commonly performed in the home setting by a parent/guardian or caregiver take on a more complex dimension in the school setting. Often parents/guardians and school administrators are confused about why what appears to be a simple task is held to a much different and higher standard at school (Resha, 2010). One of the challenges to delegation in the school setting is that parents/guardians and school administrators may not recognize that there is a requirement for medical orders for any health-related procedures in the school setting and that nurses are held to a higher protocol standard than a parent/guardian would be when delivering the same procedure at home (Resha, 2010). The school nurse practices in the educational setting where nurses support the primary purpose of providing education and must comply with state and federal mandates, nursing licensure standards and meet the expectations of parents/guardians, while working to ensure the health and safety of all students.
Supervision of delegated nursing tasks means the delegating registered nurse must supervise or periodically monitor and assess the capabilities and competencies of the UAP to safely perform delegated tasks. Unless otherwise guided by state law, the registered nurse determines how closely to supervise and how often to reassess an unlicensed individual. If an individual, who has been assigned by a school administrator, is not competent to complete the task, whether due to lack of education, attentiveness, availability or proximity, the registered nurse must work with administration to identify a more qualified individual. Until that person can assume the responsibility of delegation, the school nurse may need to directly provide the care needed by the student. The registered nurse adheres to state laws regulating nursing and standards of nursing practice, even if it is conflicts with an administrator’s directives.
School districts must have a clear, concise, all-inclusive policy in place to address the use of delegation within the school setting, and it should be reviewed periodically. This policy should be consistent with federal and state laws, nursing practice standards, and established safe practices in accordance with evidence-based information and include the development of a developmentally appropriate Individualized Healthcare Plan (IHP) and Emergency Care Plan (ECP).
The term delegation is used in other fields, but holds a unique place and meaning in the practice of nursing. To provide for safe care, school nurses should utilize the Five Rights of Delegation (ANA & NCSBN, 2006) to guide their assessment of whether delegation is appropriate for the student and the situation.
The Right task
The Right circumstances
The Right person
The Right directions and communication
The Right supervision and evaluation
When a review of the Five Rights of Delegation indicates that delegation is appropriate, the school nurse must develop an individualized healthcare plan (IHP), based on the medical orders, outlining the level of care and healthcare needs of the student and indicating which nursing tasks can and cannot be delegated. Further, the continuous process of evaluation should be based on outcomes of care, ensuring that the delegated task is completed properly and produces the desired outcome.
Delegation is not appropriate for all students, all nursing tasks, or in all school nurse practice settings. Neither the American Nurses Association nor the National Council of State Boards of Nursing support delegating steps in the nursing process, including nursing assessment or the use of nursing judgment (ANA & NCBSN, 2006). Key factors guiding determination for delegation include the following: state laws, rules, and regulations; the five rights of delegation; safety issues; healthcare needs of students; school practice characteristics; and UAP competence.
NASN supports, in states where laws and regulations allow, delegation in the school setting. By law, the appropriate professional to delegate nursing tasks in the school setting is the school nurse. Delegation is a complex skill requiring professional clinical judgment, critical thinking, and final accountability for care of the client (ANA, 2012). Delegation is a strategy the school nurse can use when planning for care. It requires both knowledge and practice to become comfortable and competent in delegation. Effective delegation in school nursing practice requires a school nurse who has the requisite skill, expertise and authority to practice in the state in which the delegation occurs. Delegation is a valuable tool for meeting the healthcare needs of students in a challenging healthcare environment and in assuring that resources are managed both safely and effectively.
American Academy of Pediatrics. (2009). Policy statement: Guidance for the administration of medication in school. Pediatrics, 124, 1244
American Nurses Association. (2012). Principles for delegation by registered nurses to unlicensed assistive personnel (UAP). Silver Spring, MD: Nursesbooks.org.
American Nurses Association & National Council of State Boards of Nursing. (2006). Joint statement on delegation. Retrieved from ttps://www.ncsbn.org/Delegation_joint_statement_NCSBN-ANA.pdf
Federal Interagency Forum on Child and Family Statistics. (2013). America’s children: Key national indicators of well-being, 2013. Washington, D.C.: U.S. Government Printing Office. Retrieved from http://www.childstats.gov/pdf/ac2013/ac_13.pdf
Gelfman, M. H. (2005). Special education law. In N. C. Schwab & M. H. Gelfman (Eds). Legal issues in school health services: A resource for school administrators, school attorneys, and school nurses (pp. 373-394). Lincoln, NE: Authors Choice Press.
Gordon, S.C., & Barry, C.D. (2009). Delegation guided by school nursing values: Comprehensive knowledge, trust, and empowerment. The Journal of School Nursing, 25, 352-360.
Mitts, Carol v. Hillsboro Union High School district 3-8 Jt et al., Washington County Circuit Court Case 87-1142C (1990).
Resha, C. (2010). Delegation in the school setting: Is it a safe practice? The Online Journal of Issues in Nursing, 15(2). doi: 10.3912/OJIN.Vol15No02Man05
U.S. Department of Health and Human Services. (2006). Section 504 Rehabilitation Act 1973. Retrieved from http://www.hhs.gov/ocr/504.html
Van Cleave, J., Gortmaker, S., & Perrin, J. (2010). Dynamics of obesity and chronic health conditions among children and youth. Journal of the American Medical Association, 303(7), 623-630.
Weydt, A. (2010). Developing delegation skills. The On-line Journal of Issues in Nursing, 15(2), Manuscript 1. doi: 10.3912/OJIN.Vol15No02Man01
Acknowledgement of Authors:
Joan Cagginello, MS, BSN, RN
Mary Blackborow, MSN, BSN, RN
Jessica Porter, BSN, RN, NCSN
Jody Disney, PhD, RN, NCSN
Kathleen Andresen, DNP, RN
Christine Tuck, MS, BSN, RN, NCSN
Revised: 2010, June 2014
All position statements from the National Association of School Nurses will automatically expire five years after publication unless reaffirmed, revised, or retired at or before that time.